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Use of Infrared Thermography in The Clinical Assessment of Chronic Testicular Pain With Possible Radicular Origin: A Case Report
Use of Infrared Thermography in The Clinical Assessment of Chronic Testicular Pain With Possible Radicular Origin: A Case Report
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João Alberto de Souza Ribeiro1,2, Alexandre Aldred2, Ivan Cesar Desuó2, Guilherme Gomes2,3
1. Department of Science, Termodiagnose Institute, São Paulo, Brazil
2. Department of Science and R&D, Predikta Soluções em Pesquisa, São Paulo, Brazil
3. University of São Paulo, USP, São Paulo, Brazil
SUMMARY
Chronic scrotal pain is a condition characterized by pain or discomfort in the scrotal contents that lasts for more than 3
months and significantly interferes with the patient's daily routine. It can have various causes, including several diseases,
syndromes, and nerve compression, affecting over 100,000 men annually in the US, and requires a multidisciplinary ap-
proach for proper management.
This report presents a case of chronic testicular pain in a sedentary 65-year-old man who reported persistent pain in the
left testicle, proximal medial thigh, and inguinal area for 4 years, which worsened throughout the day and affected his
quality of life. Infrared thermography (IRT), a non-invasive technology that measures infrared radiation emitted from ob- jects
and has been used in various medical specialties, was employed in the clinical workup. This case report describes the potential
use of IRT in the investigation of chronic testicular pain with an unclear etiology, where a possible radicular ori- gin was
considered, and discusses the potential use of this technology as a non-invasive propaedeutic tool that can pro- vide clues
to autonomic dysfunctions possibly associated with chronic testicular pain.
Key-words: Chronic testicular pain, infrared thermography, radiculopathy, urology, case report
Introduction
Chronic testicular pain, chronic scrotal pain, chronic orchi- Its causes are diverse, most commonly caused by hydrocele,
algia, testalgia, and testicular pain syndrome are terms that spermatocele, varicocele, testicular and paratesticular tu-
refer to the so-called Chronic Scrotal Pain [1]. According to mors, and infectious or inflammatory diseases of the epi-
the International Association for the Study of Pain (IASP), didymis leading to chronic epididymitis [3]. In addition,
pain is defined as "an unpleasant sensory and emotional ex- post-vasectomy pain syndrome, post-herniorrhaphy nerve
perience associated with actual or potential tissue damage" compression, pelvic muscle hypercontraction, calculous
[2], and when persistent for more than 3 months, is effec- ureteral obstruction, hip diseases, retroperitoneal tumors,
tively qualified as chronic pain. Therefore, "Chronic Scrotal and intervertebral disc diseases [3] contribute to the etio-
Pain" is a condition of pain or discomfort in the scrotal logical diversity of this condition. In the United States,
contents (including the spermatic cord, epididymis, and/or chronic pain in the scrotal region represents about 5% of
testicle) that can be continuous or intermittent, lasting for urological consultations and about 1% of medical consul-
more than 3 months and significantly interfering with the tations in primary health care services, affecting over
patient's daily routine [1]. 100,000 men annually, at a cost exceeding 55 million dollars
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Thermology international 33/2 (2023)
[1,4]. According to the European Association of Urology, charged by his urologist based on the fact that his pros-
management of scrotal pain syndrome should preferably tate-specific antigen (PSA) level was trending towards zero,
be multidisciplinary [5] and can often be a source of great and the patient remained asymptomatic.
frustration not only for the patient but for anyone involved 2018
in its diagnosis and treatment [6,7]. Approximately 10 years later, the patient started experienc-
Infrared thermography (IRT) is based on a set of sensors ing left testicular pain that radiated to the inguinal region,
capable of measuring the infrared radiation emitted from medial thigh, and left flank, which progressively worsened
any object with a temperature above absolute zero [8, 9], throughout the day, daily. The patient continued to experi-
which transforms the captured data into an image based on ence pain of the same characteristic for around 7 months
a color scale. This technology is non-invasive, does not until he sought new urological care, where an ultrasound
emit ionizing radiation, and provides quantitative results revealed a diagnosis of a left inguinal hernia.
quickly and painlessly. It was introduced in medicine in In the end of 2018, the patient underwent left inguinal
1956 by Canadian surgeon Lawson as a promising modality herniorrhaphy by an experienced general surgeon, with
for breast cancer diagnosis [10] and has been applied in var- mesh implantation. After this procedure, which went with-
ious medical specialties [11]. Some areas suggest promising out complications at the time, the patient reported rela-
results, such as the detection of spinal radiculopathies us- tive relief of scrotal pain, but not complete relief. How-
ing IRT. Studies have reported changes in skin temperature ever, about 30 days after the procedure, he reported a re-
caused by cervical hernias [12, 13], low back pain [14, 15], currence of pain, with the same pattern as before surgery,
and low back pain with sciatica [16, 17], although this rela- but now accompanied by the clear sensation of left
tionship is not consensual and not obvious when other testicular swelling at the end of the day. The patient re-
studies are observed [18, 19, 20, 21]. ported that this was not a disabling pain condition, but the
Testicular pain syndrome is a condition with universal dis- persistence of symptoms "took away his will to live".
tribution. Its multiple origins can make the etiological diag- The patient remained with pain refractory to simple analge-
nosis and even management a frustrating challenge for the sics, non-steroidal anti-inflammatory drugs, and weak
patient and the entire therapeutic team, especially when opioids such as tramadol and codeine, hoping that the pain
available imaging exams do not sufficiently clarify the con- would improve, and so he remained for almost 2 years.
dition. This case report describes how IRT was employed
in the clinical investigation of a case of chronic testicular 2021
pain without an etiological diagnosis obtained with the use In 2021, he sought evaluation from a chiropractor, whose
of other imaging techniques, in which a possible radicular therapy did not result in relief, and then an experienced or-
origin was assumed. thopedist initiated a detailed diagnostic assessment. In the
absence of orthopedic abnormalities that could justify his
Clinical and Epidemiological Findings pain, the patient sought the help of a new urologist, who
This report adheres to the CARE guideline [60] for de- ordered new imaging exams
scribing a case of chronic testicular pain in a 65-year-old
Afro-Brazilian man who is retired from a technical-admin- None of these specialists were able to present a justifiable
istrative service, with a height of 1.73m and a sedentary etiology for the painful condition.
lifestyle. The patient has a BMI within the expected normal 2022
range for his age, sex, and body type, and a medical history In 2022, when seeking evaluation from a pain management
of systemic arterial hypertension, hypothyroidism, dys- certified physician, the patient reported that his painful
lipidemia, gastroesophageal reflux disease, and mild gastri- condition had not changed, maintaining the sensation of
tis, which he reports being adequately monitored, treated, having a swollen left testicle, even though the ultrasound
and controlled. He denies any previous history of sexually examination showed a slight reduction in testicular volume
transmitted diseases, multiple sexual partners, or vasec- on the left side. In the absence of relevant results from the
tomy. The patient presented to a pain medicine service with anatomical/radiological investigation, the pain doctor rec-
pain in the left testicle, proximal medial thigh, and inguinal ommended performing a full-body infrared thermography
area, which had been persistent for approximately 5 years. exam.
The pain had an intermittent pattern associated with burn-
ing and tightness, absent in the morning and progressively
worsening throughout the day, culminating at night and af- Diagnostic Assessment
fecting his sleep quality. Orthopaedic Assessment (2021)
• Pelvic radiography showed no structural or morpholog-
Medical Timeline ical abnormalities;
2008 • Total spine radiography for scoliosis and lumbosacral
The patient reported that in 2008, he was diagnosed with spine revealed an "S"-shaped scoliosis with convexity to
prostate cancer and underwent a radical prostatectomy. He the right in the thoracic spine and convexity to the left in
the lumbar spine, with left iliac crest elevation of 1.3 cm
remained under medical care for 5 years and was dis-
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Original article
compared to the right. Marginal osteophytes were ob- Several studies have addressed the role of IRT in re-
served, but no other structural or morphological abnor- searching the Autonomic Nervous System (ANS) [28, 29,
malities. 30], indirectly identifying sympathetic activation through
the modification of heat exchanges with the environment
• Dorsal spine magnetic resonance imaging showed slight by regulating skin perfusion [28]. This feature, in particu-
signal increase in the vertebral body of T3, discrete inter-
apophyseal and costo-vertebral degenerative changes; no lar, makes IRT a potential resource for the study of pain.
relevant radicular compression or medullary or radicular It is important to note that while pain as a stressor acti-
abnormalities were evidenced; vates the Sympathetic Nervous System (SNS), the activa-
tion of the Autonomic Nervous System (ANS) can suppress
• Lumbar spine magnetic resonance imaging showed or, in pathological states, increase pain. Such interaction
slight disc protrusion with slight narrowing of the neural can occur both peripherally and in the Central Nervous
foramen at L3-L4 without radicular conflict and asym-
metric disc protrusion between L4-L5, slightly larger on System (CNS) [31, 32].
the left, but without radicular conflict; however, the pres- The most relevant thermograms for this report are pre-
ence of edema in the interspinous ligament with a proba- sented below:
ble mechanical origin was evidenced.
Urological Assessment (2021)
• Scrotal ultrasonography revealed a small hydrocele, mild
ectasia of the pampiniform plexus vessels without reflux
on the Valsalva maneuver, and mild volumetric reduction
of the left testicle;
• Abdomen and pelvis computed tomography without
contrast revealed small hepatic and renal cysts (bilateral)
and renal microlithiasis on the left side without ureteral
dilation on this side;
• Lumbosacral spine computed tomography showed pre-
served osteoligamentary morphology with minimal
marginal osteophytes. It also showed slight protrusions
of the posterior margin of the intervertebral discs at L3-
L4 and L4-L5, straightening the anterior contour of the
dural sac, but did not show radicular compression,
Figure 1:
spondylolysis, or spondylolisthesis. apparent thermographic asymmetry between the inguinal re-
gions, less radiant on the left - regions corresponding to the
Pain Medicine Assessment (2022) innervation of the iliohypogastric and genitofemoral nerves
topography (and also to the dermatome relative to L1) [33] -
Full Body Thermography with DTavg of the ROIs (Regions of Interest) of 0.4°C.
The exam was performed in a controlled environment using
a FLIR T430sc infrared sensor (FLIR® Inc. Sweden), with a
thermal resolution of 320x240 pixels, focal length of 0mm,
thermal sensitivity of 30mK, and exposure time of 1/59 s.
The patient was completely undressed, covered only by a
very thin and breathable non-woven gown that was insuffi-
cient for heat retention for a 15-minute period of thermal
stabilization and acclimatization, which is an accepted stan-
dardization in international literature [22, 23, 24, 25], in an
environment at 23.0±1.0 ºC [25], a well-documented mea-
sure of thermal comfort in Brazil [26, 27], and recom-
mended by the Brazilian Association of Thermology [23]
because it is not cold enough to cause shivering or muscle
spasms, and adjusted to the population of this country. Mini-
mal air convection (0.2 m/s) and relative air humidity below Figure 2:
apparent thermographic asymmetry between the medial-pro-
60% [23] were also ensured by a thermo- hygrometer. This ximal regions of the thighs, suggesting less radiant on the left
study consisted of 39 thermal images covering 90 neuro- - regions corresponding to the dermatomes relative to L2
vascular territories bilaterally, with additional thermograms and L3. Thermal analysis of the scrotal sac in this selection
taken in positions for exposure of the perineum for evalua- suggests apparent thermographic asymmetry between the to-
pographies of the testicles, more radiant on the left with
tion of the testicles and the proximal medial region of the
DTavg between the selections of 0.4°C.
thighs. Subsequently, the images were analyzed using Re-
searchIR+ software (FLIR®, FLIR Research IR Max 4.4.
2017, FLIR® Inc).
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Thermology international 33/2 (2023)
Figure 3: Figure 5:
apparent thermographic asymmetry in the thoracolumbar to- definition of ROIs in LEFT and RIGHT in apparent thermo-
pography, suggesting a coalescent hot-spot image to the axial graphic asymmetry suspected during the clinical-thermological
and paraspinal topography with no contralateral corresponden- examination and region of apparent lower infrared radiation in
ce. the left hip topography (arrow).
Additionally, the patient was asked to fill out a pain map, as However, the patient explained that the pain did not travel
part of the thermological examination in cases of chronic laterally down the leg, but he wanted to show that the pain
pain investigation: was in the left leg. This statement can be verified by the
way the patient represented his pain in the left lateral
drawing (Figure 4-c).
In the thoracolumbar region, although there are no consis-
tent data in the medical literature to support this, attention
was drawn to the apparent thermographic asymmetry
paraspinal to the left and relatively lower infrared radiation
in the left hip region (Figure 5) when compared to the
contralateral side. The physician responsible for investigat-
ing the pain empirically performed a moderate intensity
mechanical compression test on the area of higher hy- per-
radiation using a tennis ball (in the topography marked as
Figure 4: LEFT in Figure 5). Interestingly, with compression, the
pain map filled out by the patient as part of the pain and ther- patient reported an aggravation of scrotal pain, in addition
mological clinic examination. to a pulling sensation in the topography of the proximal
medial thigh to the left. This was the first clue that the re-
As can be seen in the pain map (Figure 4), in addition to the gion suggested by thermography could be directly or indi-
patient's main complaint of chronic testicular pain, which rectly related to the patient's chronic scrotal pain. Com-
was rated 4 on the verbal pain scale at the time of the exam- pression on the other side did not elicit any painful symp-
ination, he also highlighted lesser intensity pains that he toms.
was able to live with in other parts of his body. It is impor-
After the initial findings and during a subsequent medical
tant to note that the patient categorically stated that in the
appointment, the patient, who remained skeptical that the
morning (when the infrared thermography tests are per-
pain in his scrotum could have a distant origin from the site
formed by the doctor), his pain was completely tolerable,
of the pain, requested a repeat mechanical stimulation test.
but reached a score of 9 by evening (worsening progres-
Once again, compression of the left paraspinal lumbar re-
sively throughout the day), requiring him to use medication gion, this time with the fingertip, elicited testicular pain that
to sleep because the testicular pain prevented him from was reported as "slightly more intense" than during the pre-
falling asleep. In addition to the painful condition, the pa- vious test.
tient reported that he was frequently awakened during the
night due to involuntary movements of his left lower limb. Assuming that standard urological diagnostic methods for
Additionally, the patient indicated on the pain map a tolera- chronic testicular pain had been extensively applied and
ble pain in the lumbar region (Figure 4-a), inguinal and left that inguinal injuries and L1 and L2 radiculopathy could be
hip (Figure 4-a), thigh and medial leg extending to the related to the patient's reported pain [1, 33], IRT was used
foot(Figure 4-a), and discomfort in the flank and left to identify thermographic asymmetries that could provide
lateral chest (Figure 4-b). It is worth noting that the dorsal clues to autonomic dysfunctions associated with these con-
image (Figure 4-b) has a lateral marking of pain.
52
Original article
ditions. Considering that thermographic asymmetry could try, the use of IRT has gained ground as equipment has be-
indicate abnormality, even if not identified by consistent come more efficient, safe, reliable, and cheaper [35, 36]. Its
absolute temperature terms, two regions of asymmetry application in healthcare has become increasingly diversi-
were suggested: the less radiant left inguinal region (Figure fied, becoming applicable in various involved areas. When
1) and a small area in the left paraspinal thoracolumbar re- compared to other imaging methods, this technique shows
gion that was more radiant (Figure 3). Both areas indicated better performance in the etiological approach to pain,
empirical thermographic asymmetries in topographies al- both acute and chronic, obtaining greater sensitivity and
ready known in urological practice as sources of chronic specificity when additional provocative tests are used [37,
scrotal pain: inguinal hernias that could cause scrotal pain 38, 39, 40]. In addition, IRT stands out as a method for
[33, 55] and their surgical correction that could lead to re- functional evaluation of the autonomic nervous system, re-
section of the genital branch of the genitofemoral nerve vealing the neurological dysfunctions that have repercus-
[55, 56, 57], and radiculopathies in the L1 and L2 regions [1, sions on the microvascular circulation of tissues, especially
54, 58]. when addressing the skin [41].
In this report, the analysis of the thermograms was based
solely on the empirical thermographic asymmetry between
the sides - this being the most classical parameter used.
Such analysis consists of the temperature difference (DTor
other asymmetry parameter) in relation to the contralateral
side [42]. The central control of cutaneous temperature af-
fects both sides of the body uniformly and simultaneously,
resulting in almost symmetrical thermal patterns after sta-
bilization in a thermally stable environment. In a study con-
ducted by Uematsu [43] on facial, trunk and extremity
temperatures in normal individuals, cutaneous temperature
in 32 segments on the right and left sides of the body were
symmetrical. Zhang et al. [12] found that, depending on the
region of the upper limbs, for example, values greater than
the range of 0.1°C to 0.4°C could be classified as abnormal.
Figure 6: When the difference is greater than 1.0°C, the condition
side-to-side difference in the thoracolumbar area. can be interpreted as significant [43, 44, 45]. However, un-
der certain conditions, values lower than 1.0°C can also be
Subsequently, after observing a positive response to me- significant [46]. Some variations of this parameter, for in-
chanical stimulation in the more radiant asymmetrical area stance, can be used in the evaluation of breast cancer, such
in the left thoracolumbar paraspinal region, efforts were as the thermal difference between the mean of the Region
made to further characterize the apparent thermographic of Interest (ROI) and a point outside the ROI [47]. The
asymmetry. To achieve this, the ResearchIR+ software systematic application of such temperature differences for
(FLIR®, FLIR Research IR Max 4.4. 2017, FLIR® Inc) the diagnosis of neuromuscular disorders by IRT was in-
was used to extract the set of temperatures from the ther- troduced in 1973 by Duensing et al. [48]. In this study, tem-
mal matrix of the LEFT and RIGHT regions of interest perature changes were correlated with the sensory dis-
(ROIs) (Figure 5). Both ROIs were of the same dimensions tribution of nerves in lumbosacral radiculopathies. Subse-
(26 x 18 pixels), comprising a total of 468 measurements quent studies reported a direct correlation between painful
each, centered on the most medial points of each side. conditions and abnormal infrared patterns [49, 50, 51], as
Using the R programming language [59], a comparative well as a correlation between pain intensity and thermal
graph was generated between the temperatures of the two asymmetry [12, 52].
ROIs in question (Figure 6). The Anderson-Darling nor-
mality test (95% CI) indicated non-parametric samples (p It is well known, according to the international medical lit-
erature, that the testicles develop embryologically in the up-
=2e-16) and, by applying the Wilcoxon Test (95% CI) for
per abdomen and descend to the scrotum shortly before
non-parametric samples, it was found that there is a statisti-
birth. This descent is accompanied by the testicles' sympa-
cally significant difference between the two samples (p =
thetic nerve supply from the T10 to L1 segments and para-
2e-16), with an average temperature difference (DTavg) of sympathetic nerve supply from S2 to S4 [33, 53, 54]. The
0.36°C. somatic supply to the testicles and scrotum originates from
Discussion the nerve roots of L1-L2 and S2-S4 via the iliohypogastric,
ilioinguinal, genitofemoral, and pudendal nerves [33]. The
Among the methods used to measure human body temper-
genitofemoral nerve is formed by the merging of branches
ature, infrared thermography (IRT) is the only one that al-
from the L1 and L2 spinal roots, and it bifurcates into the
lows obtaining the thermal profile of Regions of Interest
genital and femoral branches after passing through the
(ROI) between thousands of thermal points (or thermal
psoas muscle.
pixels) [34]. Since 1950, initially intended for military indus-
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Original article
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Thermology international 33/2 (2023)
ORCID
João Alberto de Souza Ribeiro - https://orcid.org/0000-0002-9158-8908
Alexandre Aldred - https://orcid.org/0000-0002-2550-6783
Ivan Cesar Desuó - https://orcid.org/0000-0002-5435-9444
Guilherme Gomes - https://orcid.org/0000-0001-5875-2641
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